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	Definitions Emergency Dental Services Specialized Services Benefits, Limitations and Exclusions Renewal, Cancellation and Termination of Benefits Grace Period Reinstatement Description of Benefits and Copayments (Schedule A) Limitations and Exclusions (Schedule B)

SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS

The benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program. Please refer to Schedule B for further clarification of benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered.

Text that appears in italics below is specifically intended to clarify the delivery of benefits under this program and is not to be interpreted as CDT-2007 procedure codes, descriptors or nomenclature that are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation.

I. DIAGNOSTIC

II. PREVENTIVE

III. RESTORATIVE (Fillings)

IV.ENDODONTICS

V. PERIODONTICS

VI. PROSTHODONTICS (removable)

VII. MAXILLOFACIAL PROSTHETICS - Not Covered

VIII. IMPLANT SERVICES - Not Covered

IX. PROSTHODONTICS, FIXED

X. ORAL AND MAXILLOFACIAL SURGERY

XI. ADJUNCTIVE GENERAL SERVICES

SAMPLE OFFICE VISITS

Procedures not listed above are not covered however may be available at the Contract Dentist's"filed fees."

As used in this Schedule, "filed fees" mean the Contract Dentist's fees on file with ALPHA and charged by the Contract Dentist or Contract Specialty Care Dentist for performing a specific dental service. Questions regarding these fees should be directed to the Customer Service department at (800) 422 4234.

Emergency Dental Services
- The Contract Dentist will provide Emergency Dental Services for covered procedures whenever possible. If an Enrollee requires Emergency Dental Services and is unable to access care from the Contract Dentist, then ALPHA shall reimburse the Enrollee for the cost of such Emergency Dental Services which exceeds the Copayment. Emergency Dental Services shall be limited to listed procedures, and as described in code D9110: "Palliative (emergency) treatment of dental pain." Any further treatment of the cause of such Emergency Dental Services must be obtained from the Contract Dentist. All services are subject to the limitations and exclusions of the program.